Completed applications should be sent to:

Dudley Lodge, 143 Warwick Road, Coventry, CV3 6AT or [email protected]

Application to be typed.
Application must be fully completed, or it will not be accepted. Please include dates
where applicable and gaps in employment, or we will not be able to accept your
application.

CONFIDENTIAL APPLICATION FOR EMPLOYMENT

1
Position
Position Applied for
Date available to take up employment

2
Prepared to Work
Full Time □ Part Time □ Shift Work □ Temporary □ Casual □

Do you know anyone employed by this company? Yes □ No □ If yes, who?

3
Personal Details
Title: Surname: Forename(s):

Previous Names:

Address (inc postcode):

Tel Number (Home): Tel Number (Mobile):

National Insurance Number:

Email address:

4
Education
Schools attended from age 11 Examinations Dates Result
Subject
From To

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5
Further Education
Subject/Course Place of Education Dates Qualifications/Class of
Degree
From To

6
Most Recent Employer
(Please include details of your most recent employment below and use the spaces below to give details of other
employments, working backwards from the most recent)
Present/Most Recent Employer

Address Current/Leaving Salary £

Start Date Leaving Date (if applicable)

Job Title Reason for Leaving (if applicable)

Did this job involve working with children or If yes, please specify contact name, full
vulnerable adults? address details, email address and contact
number. (we are unable to pursue your
Y/N – please circle application without these details)

Duties/Responsibilities

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Previous Employer
Present/Most Recent Employer

Address Current/Leaving Salary £

Start Date Leaving Date (if applicable)

Job Title Reason for Leaving (if applicable)

Did this job involve working with children or If yes, please specify contact name, full
vulnerable adults? address details, email address and contact
number. (we are unable to pursue your
Y/N – please circle application without these details)

Duties/Responsibilities

Previous Employer
Present/Most Recent Employer

Address Current/Leaving Salary £

Start Date Leaving Date (if applicable)

Job Title Reason for Leaving (if applicable)

Did this job involve working with children or If yes please specify contact name, full address
vulnerable adults? details, email address and contact number. (we
are unable to pursue your application without
Y/N – please circle these details)

Duties/Responsibilities

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Previous Employer
Present/Most Recent Employer

Address Current/Leaving Salary £

Start Date Leaving Date (if applicable)

Job Title Reason for Leaving (if applicable)

Did this job involve working with children or If yes, please specify contact name, full
vulnerable adults? address details, email address and contact
number. (we are unable to pursue your
Y/N – please circle application without these details)

Duties/Responsibilities

Please complete this section to explain any gaps in employment/education (Specify

dates and reasons, any employment gaps since leaving school must be documented)
Where previous work has involved working with children or vulnerable adults full
contact details should be specified.
(Please continue on a separate sheet if required)

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Please detail:
(a) Reasons for applying for this position
(b) Your experience relevant to this position
(Please continue on a separate sheet if required)

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7
General
Community/Volunteer Experience
Name & Address of Position & Duties Duration & Dates
organisation

8
Vehicle
Do you own a car? Yes □ No □
Hold a current Driving Licence? Provisional □ Full □ No □
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Have any current endorsements? Yes □ No □

9
Interests/Hobbies
Please give details of any pastimes, sports
etc and offices held in social/sports clubs
etc

10
Right to work in the European Community (EC)
Do you need a work permit to work in the UK? Yes □ No □
As required by the Immigration, Asylum & Nationality Act 2006, if offered employment you will be
required to provide documentary evidence of your right to work in the EC. This can be a UK Birth
Certificate or Passport; a Passport issued by the Government of any Member Country of the European
Community; or if a citizen of a nation outside the EC that you have been given valid and subsisting
leave to be in the United Kingdom and that leave does not restrict you from taking the job for which
you are making application.
(please advise below which copy documents you will provide)
In addition, you will also need to provide two current documents / letter on which your name and
address are shown.

Documents provided:

** Note: If you require a work permit to work in the UK, you will need to provide this along with your
passport and proof of address

If you do not require a work permit to work in the UK, you must be able to provide your Passport or full
Birth Certificate with proof of your NI number.

Without these documents you will be unable to commence employment with Dudley Lodge.

11
References

Dudley Lodge adhere to a safer recruitment process, where any candidate who has
worked with vulnerable adults or children since leaving school if successful in post
each employer will need to be contacted and necessary checks will be carried out.
These checks will be carried out in line with the last 18 months of employment.

Professional Referee (We require references to cover 18 months of work and where you have
worked with children or vulnerable adults since leaving school, starting with your most recent employer)

Most Recent Employer, Company Name Referee Name

Address Position/Relationship
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Telephone Number Contactable prior to interview?
E-mail Address

Professional Referee (We require references to cover 18 months of work and where you have
worked with children or vulnerable adults, starting with your most recent employer)

Most Recent Employer, Company Name Referee Name

Address Position/Relationship

Telephone Number Contactable prior to interview?

E-mail Address

12
Next of Kin
Please give details of next of kin or person
who can be contacted in an emergency

Name Address

Tel Number (Home) Tel Number (Mobile)

Tel Number (Business) Relationship

13
Recruitment Policy
It is the Company’s policy to employ the best person for the vacancy and provide equal
opportunities for the advancement of employees including promotion and training and not to
discriminate against any person because of age, disability, gender re-assignment, marital status,
race, religion, belief, sex, sexual orientation, or union membership status.

I authorise the Company to obtain references to support this application once an offer has been
made and accepted and release the Company from any liability caused by giving and receiving
information.

Declaration
I confirm that the information given on this form is, to the best of my knowledge, true and
complete. Any false statement may be sufficient cause for rejection or, if already an employee,
dismissal.

Signature: Date:

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14
How did you hear about this position?
Please tick
Please tick below, where or how you heard about the vacancy at below
Dudley Lodge:

1. Friends Recommendation (please see below)

2. Via the Dudley Lodge website ‘Careers’ section
3. Via advertisement in the local newspaper
4. Other, please specify

………………………………………………………………………………

If this is a friend’s recommendation, please include full name below:

............................................................................................................

If you downloaded the application pack from the Dudley Lodge website,
please specify how you were directed to our website:

………………………………………………………………………………

Application Form Guidance Notes

Thank you for your interest in this vacancy at Dudley Lodge. These guidance notes have
been written to help you complete the application form as fully as possible.
Completing the Form
The application form may be downloaded and word processed (visit www.dudley
lodge.co.uk under careers section to download the form). Please ensure you tell us the job
title and reference number of the post for which you are applying.

Personal Details
We will require this information to contact you should you be short listed for the interview
so please complete this as fully as possible.

We are committed to safeguarding and promoting the welfare of the children; therefore,
the post is subject to an enhanced DBS check.

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References
Dudley Lodge adhere to a safer recruitment process, where any candidate who has
worked with vulnerable adults or children since leaving school if successful in post each
employer will need to be contacted and necessary checks will be carried out. These
checks will be carried out in line with the last 18 months of employment.

You should give the name, occupation and addressees of people who will provide a
reference for you. Your referees should include your present or most recent employer. If
you have not yet been employed, then your referee may be someone who taught you at
school or college.

Referees should be able to comment authoritatively on your work, education, skills and
abilities and must not be related to you.

Disclosure & Barring Scheme Checks

Because of the nature of Dudley Lodge’s work, any member of staff or volunteer may
come in to contact with children under the age of 18 or vulnerable adults. Therefore, the
post for which you have applied is exempt from the previous of section 4 (2) of the
Rehabilitation of Offenders Act1974, by virtue of Rehabilitation of Offenders Act 1974
(Exceptions) Order 1975 and the Rehabilitation of Offenders 1974 (Exceptions)
(Amendments) Order 1986. Consequently, you are not entitled to withhold information
about convictions which for other purposes are ‘spent’ and in the event of your
employment any failure to disclose such convictions may result in dismissal.
If you have any convictions then we will request you please provide details at a later stage
of the interview process. This information will be treated as confidential and will not
necessarily preclude you from employment.

Qualifications Obtained at School

Please let us know the qualifications you gained at school, the year you gained them, the
grade and the level of qualification e.g. GCSE, O ’Level, NVQ.

University/Further Education
Please let us know the name and dates of any higher or further educational
establishments you have attended along with the details of qualifications and grades
obtained.

Other Job Related Training

Tell us about any job related training courses you have attended.

Membership of Professional Bodies

If you are a member of any professional body then please let us know and remember to
include your membership status e.g. associate, graduate.

Present Employment
You should tell us the name and address of your present employer, along with the date
your employment commenced and your present salary or grade.

Current Duties and Responsibilities

Please also briefly describe your current duties and responsibilities focusing on those
which would of interest to us when considering the post for which you have applied.

Other Employment / Voluntary Work

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Use this section to tell is about employment history. Please list the names, addresses and
nature of business of your previous employers, together with a very brief description of
your job purpose and duties.

Personal Statement
Addressing the selection criteria
Your application criteria should address each criterion by demonstrating how your work
experience, skills, knowledge, abilities and qualifications meet them. Criteria may often be
referred to as ‘essential’ or ‘desirable’.
Essential criteria – refers to those that are critical for the satisfactory performance of the
pos.
Desirable Criteria – are those which, while not essential, will enhance your capacity to do
the job.

Equal Opportunities
Dudley Lodge is committed to a policy that seeks to ensure equality of opportunity for all
and to take action to avoid discrimination. All applicants are considered solely on their
perceived ability to do the job for which they have all applied. Therefore, it would be
appreciated if you could complete the separate form in full.

Declaration
Please remember to sign and date the form before you post it to us.

Please return your application form before 5pm on the closing date to:
[email protected]

HR & Recruitment Team

Dudley Lodge
43 Warwick Road
Coventry
CV3 6AT

If you have not heard from us within 2 weeks of the closing date, you may assume that
your application has been unsuccessful. It is not our policy to provide feedback. Any
unsuccessful applicant can only apply for another similar position after 12 months has
elapsed unless there are exceptional circumstances.

Data Protection
The information you provide is subject to the Data Protection Act 1998, unless you are
appointed to the job for which you have applied, will be stored securely in the Personnel
Department for a period of six months, after which it will be destroyed. We keep
applications on file as there may be times when positions come up that may be of interest
to you. If you do not want your application kept on file for 6 months please email
[email protected] to let us know to take your details off our records.

Equalities in Employment Monitoring Form

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The information on this monitoring form is required by Dudley Lodge to assist us to implement equalities and diversity within the
organisation. Your personal details will be used for internal statistical purposes and for anonymous reporting to Trustees. You will not
be contacted as a result of any information supplied on this form. The form complies with the requirements of the Data Protection Act
1998.

Applicants are not required to complete the information on this form in full or in part and declining to do so, will not prejudice your
application. All information will be treated in confidence and will not be used as part of the selection process. This monitoring form will
be separated from the application form on receipt at Dudley Lodge and will not be seen by the recruitment panel.

Job Title ………………………………………………………………………………………………………..

How did you learn of this vacancy? ………………………………………………………………………..

Name of publication/website?(if appropriate)….…………………………………………………………...

Date of Birth: ………………………………… Nationality …………………………….

Gender: (Please tick one box) Male  Female 

Gender Recognition: Have you gender recognition status or applying for a certificate? Yes No

Sexuality: Heterosexual  Bisexual  Lesbian  Homosexual 

Do you consider that you have a disability?

(Please tick one box) Yes  No 

The Equality Act 2010 describes disability as ‘a physical or mental impairment that has a substantial and
long-term effect on your ability to carry out normal day-to-day activities’.

I would describe my ethnic origin as being? (Please tick one box below)

White British  Irish 

Any Other White Background 
Mixed White & Black Caribbean  White & Black African 
White & Asian  Any Other Mixed Background 
Asian or Asian British Indian  Pakistani 
Bangladeshi  Any Other Asian Background 
Black or Black British Caribbean  African 
Any Other Black Background 
Chinese or Chinese  Any Other Ethnic Group 
Other Ethnic Group (please specify)
………………………………...

These ethnic origin categories are taken from the 2001 census circulated by the Office for National Statistics.

Signed: ………………………………………………………………. Date: ………………………………

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 Dudley Lodge is committed to Quality, Excellence, Equality and Diversity
If you are applying for a Bank Family Worker role or Waking Night Worker role
please tick your availability.

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Please be aware of working time regulations. Employees must have 1 rest day in a
7-day week, for this reason please make Dudley Lodge aware of any other work you
will be undertaking below:

Currently working days/hours:

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